A Neuropsychiatric View of Insomnia

(1963) remarked in what remains a classic study of sleep and wakefulness, ithere are more books and articles devoted entirely, or mainly, to the discussion of insomnia than to any other trouble connected with sleep, but they are for 'the most part to? general to comment upon. ti Goethe wrote : ' should be glad if, when people come to a clear Uriderstanding in natural science, they would stick to truth, and not go transcendent again after all has been done in the region of the comprehensible". (Conversations). A great deal of work has been done on sleep in recent years, in centres all over the world, on man and on animals, and from the standpoint of different disciplines. I shall try to summarise some of this work which seems to me interesting and relevant to the subject of insomnia.

remarked in what remains a classic study of sleep and wakefulness, ithere are more books and articles devoted entirely, or mainly, to the discussion of insomnia than to any other trouble connected with sleep, but they are for 'the most part to? general to comment upon.
ti Goethe wrote : ' should be glad if, when people come to a clear Uriderstanding in natural science, they would stick to truth, and not go transcendent again after all has been done in the region of the comprehensible". (Conversations). A great deal of work has been done on sleep in recent years, in centres all over the world, on man and on animals, and from the standpoint of different disciplines. I shall try to summarise some of this work which seems to me interesting and relevant to the subject of insomnia.
Changes in the electroencephalogram in relation to behaviour and level of awareness have probably been most clearly described by L'indsley (1952) (Table I) Absent This description suggests that there are three main kinds of natural sleep and further studies have defined a fourth, and most interesting stage, known as paradoxical or rapid eye movement (REM) sleep, which is found in both man and animals, and first described by Dement and Kleitman (1957). Detailed all-night studies of these stages have since been made by many workers (Jouvet, 1965;Oswald, 1966, Luce andSegal, 1969;Evans 'and Jones, 1969) and a number of pertinent observations made: The night consists normally of an initial period of deep slow-wave sleep, punctuated by 4 or 5 REM periods, occurring with a periodicity of about 90 minutes. Deep sleep is not remembered, though some mental life occurs in it, as occasional dream reports have been obtained when people were aroused from this stage. Sleep walking and nocturnal enuresis are initiated, and most muscular movements occur in this stage.
Dream reports are obtained almost universally on arousal from paradoxical (REM) sleep and the dreams often remembered. This stage is called paradoxical because an EEG pattern of rapid cortical activity is coupled with a behavioural stage of deep sleep?if the latter is judged by almost total muscular atonicity and, in fact, a considerable raising of the waking threshold (Jouvet, 1967). It is thought that the rapid eye movements represent following of visual images in dreams. Paradoxical sleep is the first sleep in narcolepsy and is the stage in which "sleep paralysis" and nightmares occur. Amphetamine and monoaminoxidase inhibitors increase the proportion of REM sleep; barbiturates greatly ieduce it, but barbiturate withdrawal results in an increase of REM sleep, dreaming and nightmares for a period as long as a month. Sleep laboratory studies of people who report little or no sleep usually show a normal pattern; the paradoxical phases are remembered and equated with waking, whereas long periods of deep sleep are forgotten and, of course, the sense of time is totally disorganised in all phases of sleep.
The pattern of sleeping and iwaking depends on a complex relationship between neural and chemical elements: There are small collections of cells in the brain-stem, pons and in the region of the third ventricle, forming part of the reticular system, stimulation of some of which will cause arousal and ethers, sleep. The latter cells have a high serotonin content and, in cats, 80% destruction of these cells resulted in almost complete insomnia (Jouvet, 1967). Instillation of serotonin in the brain-stem caused cats to drop immediately to sleep in their food-bowls (Koella et al., 1965). Jouvet (quoted in Luce and Segal, 1969) abolished REM sleep in cats for 4-5 days with a single injection of reserpine, and reversed this effect with DOPA, a precursor of noradrenaline.
Experimentally, dialysed brain-blood from a sleeping animal has produced sleep in a waking animal (Monnier and Hosli, 1964). Clearly the cortex takes part in the sleeping pattern, for not only is sleep in part a learned response and a habit, but lilt lis common experience, Which has been confirmed by experimental observation (Oswald, 1966), that significant stimuli cause arousal, whereas equally intense stimuli, which are not significant for the particular individual, do not. Thus the mother wakes at the first cry from her child, while the trains go by unheeded and father snores throughout.
There is a diurnal periodicity in a wide range of physiological functions as well as in sleeping and waking (Mills, 1969), and these variations, known as Circadian Rhythms, are found in the simplest of organisms, as well as in man (Bunning, 1967). When men are put in conditions isolated from (the usual means of telling the time, such as in caves, North of the Arctic Circle (Oswald, 1966) or in conditions of experimental sensory deprivation, it is found that they live on a day slightly longer than 24 hours, >and that about 8 hours' sleep occurs in that period. Numerous medical and psychiatric conditions which disturb Circadian Rhythms (Knapp, 1969) also disturb sleep, as does jet travel across the meridians of time; with regard to the latter, adaptation occurs in about four days. Shift work, although it has its problems, gives rise to many complaints, and has a very variable effect on individuals (Taylor, 1969), causes far less disturbance of the sleep pattern than one might suppose. A controlled study showed that shift workers took more sleep than controls, had fewer disturbances of the main sleep period, and that they built up a sleep debt while working, which was paid off by long naps during days off' That we spend about a third of our lives sleeping and that we need this is beyond doubt. Animals continuously deprived of sleep eventually die; humans experimentally deprived of sleep developed impaired performance and transient psychotic states, and sleep' deprivation is a well known interrogator's tool in the process of brain-washing and inducing conversion and false confessions (Sargant, 1959). Prolonged sleep loss produces a marked reduction of alpha activity in the EEG, which overrides circadian variations and individual differences (Naitch et al, 1969). There is evidence, too, that we need both deep and paradoxical, dreaming sleep, for -selective deprivation of either leads, as the case may be, to an increased proportion of deep or REM sleep in the ensuing undisturbed nights. This has led people to suggest that we need to dream, which is intriguing, but for which as yet there is no conclusive evidence. Freud (1929) likened the dream to a night watchman, a guardian of sleep, whose purpose it is to protect sleep from interruption. If the censorship, as he termed it, feels powerless against some dream wish which threatens to overthrow it, then, instead of making use of distortion, destroy5 sleep by bringing about an access of anxiety. Because of partial abrogation of the censorship in favour o' sleep at night, forbidden wishes can become active ?nd he goes on to say, "There are nervous people suffering from insomnia who confess that their sleeplessness was voluntary in the first instance; for they did not dare to go to sleep because they were afraid of their dreams." Except to adduce evidence that we need sleep, we are still not in a position to say exactly why we have this need. Evans (1969) drew an analogy wit11 the computer, Which has to be programmed when it |S "off-line", and suggested that sleep might be an line" period when the 'brain processed data acquired during the day, related it to similar and past experience, and built up the memory store.
People vary a great deal in the amount of sleep they seem to need for optimum efficiency, but average is the traditional 8 hours. Sleep habits, in s? ar as they are learned, are probably acquired in child-??d. The difference in individual patterns can give ['se to difficulties, for example in marriage : She has ito go to bed at ten. I do at midnight. Then hen I go to bed, she's already asleep." She i:kes a lot of blankets. I don't. So we had to take ^?n beds and that ruined our sex life". "hough we all build up often quite elaborate rituals ,0r going to sleep it is remarkable how these rituals ave been observed to go in times of disaster, as with earthquakes, war-time experiences and concentration c^ps. ^ decreasing amount of sleep is taken as age Creases and this is paralleled by increasing comaints of insomnia with age. McGhie and Russell l ^62) found that 7% of people under 40 said they 'sss than 5 hours sleep at night, and this rose to I with frequent early waking 'in the over-70's. There also a sex difference, for 30% of females over 65 longer than 90 minutes to fall asleep, but few of e Tien. Dissatisfaction with sleep, as reflected 'by the err>and for drugs, increases with age, so that by the 9e of 75t 45% 0f women were regularly taking sleep-Pills. In  Won 'n over-excitement and anticipation, as before a 0r d 1 ng or an examination, the patient may get little q n? sleep without a 'hypnotic. A good dose of a g; lc^'acting barbiturate is probably best, but should be aven not less than 8 hours before rising so as to tre?lcl hang-over. Hypnotics may be 'important also in the Oaa^rnent of insomnia due to recent events which have ^U3ed anxiety, or after bereavement. But 'here I think a , ^ight pause to reflect that the first prescription of I, arbiturate may be a serious event in a person's life.
,0,ave observed that many people may take barbiturates for Vears and never exceed ithe prescribed dose, but the reas?ns already given, tew find it easy to stop re^: A few demand excessive doses, ' tyj^Ve. had no more complaints from patients or staff tro|i n'trazepam than with barbiturates. A recent coned study (Matthew et al? 1969) has shown it to be equally as effective as butobarbitone and a search of the literature and their own experience produced no evidence of dependence, withdrawal symptoms or death from overdose with as many as 80 tablets. If it seems that only a barbiturate will do, then I think Hemphill (1957) was wise ito advise that after the patient has had two or three nights' sound sleep he should be instructed to do without drugs, even at the expense of a restless night, and thereafter not to take sleeping pills on more than three nights in a week. (b) Anxiety and psychoneurosis are by far the most common and important causes of chronic insomnia. Adler (1929) described nervous insomnia in terms similar to one of Eric Berne's (1968) destructive psychological games, where the symptom is exaggerated in importance so as to serve as a signal and weapon against spouse, doctor or employer, and as evidence of illness and an excuse for the avoidance of difficulties. The patient may demand ten 'hours' sleep at the cost of a heavy hangover in the morning; this in itself can be responsible for inefficiency and inability to cope with work or house, which may have more serious consequences than the original circumstances and do much to make the neurotic condition chronic. The treatment is primarily directed to the neurosis rather than the insomnia but, in some cases, the vicious circle of tension and drug dependence may be broken by a period of continuous narcosis with non-barbiturate drugs in hospital (Bradfield, 1969). (c) In psychotic conditions, a change in the sleep pattern may be an early sign and indication for specific treatment of the illness.
(d) The disturbed sleep pattern in senility is a constant problem to the patient and to those who attend him, and there are often multiple causes which require attention; physical causes, such as cardiac or respiratory disease, or a full bladder, organic brain disease whidh, for various reasons, 'is particularly liable to give trouble at night, and morbid depression. Barbiturates often aggravate restlessness due to organic brain disease, and a combination of a suitable tranquilliser by day and a non-barbiturate at night is far better. It is important in these cases to try to establish a regular routine for going to bed, getting up, attention to bladder and bowels, and for meals and recreation. (e) Loss of the sleep habit disturbs tense and anxious people more than others who are basically more sanguine and phlegmatic, and is liable to happen with mothers who have been kept awake by babies, to shift workers and to those who have been kept alert nursing a sick person. Because the cause may continue and because of the personality factor, these cases are difficult to treat. One must try by various means to allay the anxiety, to break the chain of sleeplessness by the use of hypnotics in the manner suggested earlier, and to try to establish a more normal routine.
(f) The management of insomnia due to pain and physical illness is a subject in itself and, as I 'have been taking a mainly psychiatric view of insomnia, I shall only say that it is of course bound up with the treatment of the particular physical condition, but that one broken leg or case of heart failure is, for psychiatric reasons, not the same as another, and that the emotional reactions and attitudes, even in the most obvious physical case, should never be forgotten.